Method and apparatus for temporarily immobilizing a local area of tissue

ABSTRACT

A method and apparatus for temporarily immobilizing a local area of tissue. In particular, the present invention provides a method and apparatus for temporarily immobilizing a local area of heart tissue to thereby permit surgery on a coronary vessel in that area without significant deterioration of the pumping function of the beating heart. The local area of heart tissue is immobilized to a degree sufficient to permit minimally invasive or micro-surgery on that area of the heart. The present invention features a suction device to accomplish the immobilization. The suction device is coupled to a source of negative pressure. The suction device has a series of suction ports on one surface. Suction through the device causes suction to be maintained at the ports. The device further is shaped to conform to the surface of the heart. Thus, when the device is placed on the surface of the heart and suction is created, the suction through the ports engages the surface of the heart. The suction device is further fixed or immobilized to a stationary object, such as an operating table or a sternal or rib retractor. Thus, the local area of the heart near the suction device is temporarily fixed or immobilized relative to the stationary object while suction is maintained. In such a fashion, the coronary artery may be immobilized even though the heart itself is still beating so that a bypass graft may be performed. In addition the suction device may be used in either a conventional, open-chest environment or in a minimally-invasive environment, e.g. endoscopic.

RELATED APPLICATION

This is a divisional application claiming priority from application Ser.No. 09/334,531 filed Jun. 19, 1999 of Borst et al. entitled “Method AndApparatus For Temporarily Immobilizing A Local Area Of Tissue”, whichitself is a divisional application claiming priority from applicationSer. No. 08/725,371 filed Oct. 3, 1996 of Borst et al. entitled “MethodAnd Apparatus For Temporarily Immobilizing A Local Area Of Tissue” andwhich itself is a continuation in part of application Ser. No.08/531,363 filed Sep. 20, 1995 of Borst et al. entitled “Method AndApparatus For Temporarily Immobilizing A Local Area Of Tissue” now Pat.No. 5,836,311.

FIELD OF THE INVENTION

The present invention generally relates to surgery on body tissues andorgans. More specifically, the present invention relates to a method andapparatus for temporarily immobilizing a local area of tissue subject tomotion, such as the heart wall, which permits a surgical procedure to beperformed on that local area of tissue.

BACKGROUND OF THE INVENTION

Coronary artery disease remains the leading cause of morbidity andmortality in Western societies. Coronary artery disease is manifested ina number of ways. For example, disease of the coronary arteries can leadto insufficient blood flow to various areas of the heart. This can leadto the discomfort of angina and the risk of ischemia. In severe cases,acute blockage of coronary blood flow can result in irreversible damageto the myocardial tissue including myocardial infarction and the risk ofdeath.

A number of approaches have been developed for treating coronary arterydisease. In less severe cases, it is often sufficient to merely treatthe symptoms, with pharmaceuticals, or treat the underlying causes ofthe disease, with lifestyle modification. In more severe cases, thecoronary blockage can be treated endovascularly or percutaneously usingtechniques such as balloon angioplasty, atherectomy, laser ablation,stents, and the like.

In cases where these approaches have failed or are likely to fail, it isoften necessary to perform a coronary artery bypass graft procedure.This procedure generally consists of the following steps: First, directaccess to the heart is achieved. This is usually done by opening thechest by median sternotomy and spreading the left and right rib cageapart; and opening the pericardial sac to achieve direct access to theheart.

Next, a blood vessel or vessels for use in the graft procedure aremobilized from the patient. This usually entails mobilizing either amammary artery or a saphenous vein, although other graft vessels mayalso be used.

Next, a heart-lung or cardiopulmonary bypass is performed. This usuallyentails arterial and venous cannulation, connecting the bloodstream to aheart-lung machine, cooling the body to about 32 degrees Celsius,cross-clamping of the aorta and cardioplegic perfusion of the coronaryarteries to arrest and cool the heart to about 4 degrees Celsius. Thearrest or stoppage of the heart is generally required because theconstant pumping motion of the beating heart would make surgery upon theheart difficult in some locations and extremely difficult if notimpossible in other locations

Once cardiac arrest is achieved, then a graft (or grafts) is attached tothe relevant portions of a coronary artery (or arteries) followed byweaning from the cardiopulmonary bypass, restarting the heart anddecannulation. Finally the chest is closed.

One area which may create difficulties for the patient and extra expenseand time for the procedure involves the cardiopulmonary bypass. In acardiopulmonary bypass all the patient's blood, which normally returnsto the right atrium, is diverted to a system which supplies oxygen tothe blood and removes carbon dioxide and returns the blood, atsufficient pressure, into the patient's aorta for further distributioninto the body. Generally such a system requires several separatecomponents, including an oxygenator, several pumps, a reservoir, a bloodtemperature control system, filters as well as flow, pressure andtemperature sensors.

Problems may develop during cardiopulmonary bypass due to the reactionblood has to non-endothelially lined surfaces, i.e. surfaces unlikethose of a blood vessel. In particular, exposure of blood to foreignsurfaces results in the activation of virtually all the humoral andcellular components of the inflammatory response, as well as some of theslower reacting specific immune responses. Other complications fromcardiopulmonary bypass include loss of red blood cells and platelets dueto shear stress damage. In addition, cardiopulmonary bypass requires theuse of an anticoagulant, such as heparin. This may, in turn, increasethe risk of hemorrhage. Finally cardiopulmonary bypass sometimesnecessitates giving additional blood to the patient. The additionalblood, if from a source other than the patient, may expose the patientto blood born diseases.

Due to the risks incurred during cardiopulmonary bypass, others haveattempted to perform a coronary artery bypass graft procedure withoutcardiac arrest and cardiopulmonary bypass. For example, Trapp andBisarya in “Placement of Coronary Artery Bypass Graft Without PumpOxygenator”, Annals Thorac. Surg. Vol. 19, No. 1, (January 1975) pgs.1-9, immobilized the area of the bypass graft by encircling sutures deepenough to incorporate enough muscle to suspend an area of the heart andprevent damage to the coronary artery. More recently Fanning et al. in“Reoperative Coronary Artery Bypass Grafting Without CardiopulmonaryBypass”, Annals Thorac. Surg. Vol. 55, (February 1993) pgs. 486-489 alsoreported immobilizing the area of the bypass graft with stabilizationsutures.

While these attempts have achieved some success, they generally requireenhanced skill of the surgeon to properly create the anastomsis because,even with sutures, the beating heart continues to move in the relevantarea more than desired.

SUMMARY OF THE INVENTION

It is thus an object of the present invention to provide a method andapparatus for temporarily immobilizing a local area of tissue, such asan area of a beating heart, without requiring the use of stabilizingsutures.

It is a further object of the present invention to provide a method andapparatus to facilitate performing coronary artery bypass graft surgeryon a beating heart.

It is the further object of the present invention to provide a methodand apparatus to perform a coronary artery bypass graft withoutrequiring the heart to be arrested or stopped and the patient coupled toa cardiopulmonary bypass machine.

These and other objectives are met by the present invention whichcomprises a method and apparatus for temporarily immobilizing a localarea of tissue. In particular, the present invention provides a methodand apparatus for temporarily immobilizing a local area of heart tissueto thereby permit surgery on a coronary vessel in that area withoutsignificant deterioration of the pumping function of the beating heart.The local area of heart tissue is immobilized to a degree sufficient topermit minimally invasive or micro-surgery on that area of the heart.The present invention features a suction device to accomplish theimmobilization. The suction device is coupled to a source of negativepressure. The suction device has a series of suction ports on onesurface. Suction through the device causes suction to be maintained atthe ports. The device further is shaped to conform to the surface of theheart. Thus, when the device is placed on the surface of the heart andsuction is created, the suction through the ports engages the surface ofthe heart. The suction device is further fixed or immobilized to astationary object, such as an operating table or a sternal or ribretractor. Thus, the local area of the heart near the suction device istemporarily fixed or immobilized relative to the stationary object whilesuction is maintained. In such a fashion, the coronary artery may beimmobilized even though the heart itself is still beating so that abypass graft may be connected to the coronary artery. In addition thesuction device may be used in either a conventional, open-chestenvironment or in a minimally-invasive environment, e.g. endoscopic.

BRIEF DESCRIPTION OF THE DRAWINGS

The foregoing and other aspects of the present invention will best beappreciated with reference to the detailed description of the inventionin conjunction with the accompanying drawings, wherein:

FIG. 1 is a plan view of the device being used to temporarily immobilizea local area of heart tissue in which access to the heart is achievedthrough a mini-thoractomy.

FIGS. 2a and 2 b depict a first type of suction device shown in use inFIG. 1.

FIGS. 3a and 3 b depict a second type of suction device shown in use inFIG. 1.

FIG. 4 is a longitudinal sectional view of the suction paddle used inthe present invention.

FIG. 5 is a cross-sectional view of the suction paddle used in thepresent invention taken along the line 5—5 of FIG. 4.

FIG. 6 is a longitudinal sectional view of the suction arm used in thepresent invention.

FIG. 7 is a plan view of the suction arm used in the present invention.

FIG. 8 is a detailed view of a pair of suction devices being positionedon a heart and spread apart.

FIGS. 9 and 10 show the effect of the spread-apart motion depicted inFIG. 8.

FIG. 11 is an example of the motion in the plane parallel to the surfaceof the heart of a point on heart tissue during one half respiratorycycle when the heart is unrestrained and also depicting the motion ofthe same point on heart tissue when the suction devices are used.

FIG. 12 is an enlarged portion of FIG. 11 depicting the motion of thesame point on heart tissue when the suction devices are used.

FIG. 13 is an alternate embodiment of the present invention.

FIG. 14 is a plan view of the device being used to temporarilyimmobilize a local area of heart tissue in which access to the heart isachieved through a median sternotomy.

FIG. 15 is a side view of an alternate embodiment of the presentinvention, shown placed against the surface of the heart.

FIG. 16 is a bottom view of the alternate embodiment of the presentinvention device shown in FIG. 15.

FIG. 17 is a side view of a further alternate embodiment of the presentinvention, shown placed against the surface of the heart.

FIG. 18 is a bottom view of still further alternate embodiment of thepresent invention.

FIG. 19 is a cross-sectional view of a body showing an alternativemethod of achieving access to the surface of the heart, and inparticular of achieving such access using minimally invasive trocars.

FIG. 20A is a cross-sectional view of a body showing an alternateembodiment of the present invention, and in particular, an alternateembodiment of the securing device.

FIG. 20B is a top view of the embodiment shown in FIG. 20A.

FIG. 21 is a perspective view of a securing device.

FIG. 22 depicts an overhead view of the securing device.

FIG. 23 is a side view of an alternate embodiment of suction device.

FIG. 24 is a further alternate embodiment of a suction device.

FIG. 25 is a perspective view of an alternate embodiment of animmobilizing device.

FIG. 26A is a view of the bottom of an alternate embodiment of a suctionpaddle used in the immobilizing device.

FIG. 26B is a perspective view of a further alternate embodiment of asuction paddle used in the immobilizing device.

FIG. 27 is a perspective view of a turning handle used to bend or orientthe suction paddle portion of the immobilizing device.

FIG. 28 is a bottom view of an alternate embodiment of immobilizingdevice.

FIG. 29 is a plan view of a spreader used in an alternate embodiment ofthe present invention.

FIG. 30 depicts an alternate embodiment of spreader.

FIG. 31 depicts an alternate embodiment of immobilizing device and, inparticular, an alternate embodiment of the securing device used tosecure each suction paddle to the operating table rail.

FIG. 32 is a cross sectional view of the arm shown in FIG. 31.

FIG. 33 depicts a further alternate embodiment of the present invention,and in particular of a suction device substantially similar to thatshown in FIG. 13 but for that the suction ports are located at the topof the suction paddle.

The drawings are not necessarily to scale.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT

FIG. 1 is a view of the immobilizing device 11 being used to temporarilyimmobilize an area of heart tissue. In the preferred embodiment,surgical access to the local area of heart tissue is achieved through amini-thoracotomy, preferably performed within either the fourth or fifthintercostal space. An incision 10 of approximately 10 centimeters ismade into chest cavity between the ribs (seen here in phantom.) The ribcartilage may be temporarily removed and the ribs surrounding theincision slightly spread apart using a retractor (not shown) to provideadequate surgical access to the mammary artery and the heart. As seen, apair of suction devices 12, 13 are introduced. The first suction device12 is introduced through a small stab wound 8 in between the ribsapproximately 10 cm. below incision 10. This stab wound is made in anyacceptable manner. Incidentally, once the surgery has been completed,the stab wound may be used for the thorax drain after the closure of thechest. As discussed below with reference to FIG. 19, the suction devicehas a covering 180, made from latex rubber, over the distal end when itpenetrates the chest wall in order to avoid blood and tissue fromentering the suction ports and block suction apertures. Once suctiondevice is introduced, covering 180 is removed and the distal end ispositioned onto heart. The second suction device 13 is introducedthrough incision 10 onto the surface of the heart. As seen, the distalend of each suction device is ultimately positioned in the local area ofheart tissue to be immobilized, i.e. on either side of a coronary arteryupon which a graft is to be made.

As seen, suction devices 12, 13 are secured using securing devices 14,15 respectively to a stationary object, such as surgical table 16. Ofcourse other objects besides the surgical table may be used as astationary object, including the floor, ceiling or even the patient,such as a portion of the skeletal system of the patient, e.g. thesternum. In the preferred embodiment, each securing device 14, 15 is avariable friction arm, model no. 244 available from Manfrotto Nord, Inc.of Zona Industriale di Villapaiera, I-32032 Feltre BL, Italy. Eachsecuring device 14, 15 has a series of elbow joints 17 which may belocked in position. Thus the securing device permits the suction deviceto be locked into any position desired within three-dimensional space.Although not show, each securing device (or each suction device or both)may also be interconnected such that a truss type structure is createdand the entire stiffness or rigidity of the immobilizing device 11 isimproved.

Suction devices 12, 13 are coupled to a suction source 114 through lines20, 21. Suction source 114 is preferably the standard suction availablein the operating room and coupled to the devices with a two liter bufferflask (not shown) for each device. Suction is provided at a negativepressure of between 200-600 mm Hg with 400 mm Hg preferred. As seen,each suction device has essentially two portions, a paddle 22 and an arm23. FIGS. 2 and 3 detail suction devices 12 and 13 respectively.

Turning now to FIGS. 2a and 2 b, FIG. 2a is a side view of a suctiondevice 12 showing its placement against the outline of a heart. As seen,the distal end of suction device comprises a paddle 22 and arm 23coupled together by a continuous hinge or neck 71. Paddle 22 has agenerally planar surface which conforms generally to the curvature of aheart 1, shown here in outline. In the preferred embodiment, suction arm23 is coupled to suction paddle 22 such that suction paddle 22 may berotated or bent to achieve the desired orientation relative to arm 23.This is accomplished by neck 71. Neck 71 is fashioned to be relativelybendable, that is to be bent by hand into the desired orientation, asopposed to paddle 22 and arm 23, which are rigid. In the preferredembodiment suction paddle 22 and suction arm 23 are constructed ofstainless steel 316, while neck 71 is constructed of stainless steel321. Of course other means may be provided to permit paddle 22 to moveor rotate relative to arm 23 other than making neck 71 to be malleableby hand, such as a locking hinge as well as a remotely actuable joint,as is well known in the art. See for example, U.S. Pat. No. 5,374,277 ofHassler, incorporated herein by reference. A remotely actuable hinge isbelieved particularly advantageous for a suction device usedendoscopically. In an alternate embodiment paddle may be fixed in arigid orientation relative to arm. As seen, arm 23 has a suction lumen30 therethrough which communicates with a suction conduit 31 in paddle22 through neck lumen 72. Suction conduit 31 in paddle 22 furthercommunicates through suction hole 32 (best seen in FIG. 2b) to suctionport 33.

FIG. 2b is a view of the bottom of suction device 12. As seen, in thepreferred embodiment four suction ports 33 in a row are featured,although the specific or exact number and position used may vary. Eachsuction port 33 has a suction aperture 32, each of which are preferablylocated at a position off-center from suction port 33. Suction apertures32 are positioned off center from suction ports 33 so that if a largeupwelling of tissue is caused by the suction (which may occur as ablister or bell-shaped curve) the tissue will not immediately close offthe suction by obstructing suction aperture 32, as it would if theaperture were in the center of suction port 33. In addition, eachsuction aperture 32 has a much smaller diameter as compared to thediameter of suction port 33. This creates a high resistance pathwaybetween suction port 33 and suction conduit 31 which permits the loss ofa tissue-to-port seal in one suction port (and thus loss of fixation ofthe suction port to the tissue) to not also cause a precipitous pressuredrop in the remainder of the suction ports. In the preferred embodimentsuction aperture 32 has a diameter of 2 mm and suction port 33 has adiameter of 6 mm. As can be seen through a comparison between FIGS. 2Aand 2B the relatively straight sided suction ports define a generallyplanar surface through the ends of each port.

Turning now to FIGS. 3a and 3 b, FIG. 3a is a side view of a suctiondevice 13 shown in FIG. 1. As seen, the distal end of suction device 13comprises paddle 22 and arm 23 coupled together by a continuous hinge orneck 71. Paddle 22 has a generally planar surface which conformsgenerally to the curvature of a heart 1. In the preferred embodiment,suction arm 23 is coupled to suction paddle 22 such that suction paddle22 may be rotated or bent along any of the three axes to achieve thedesired orientation relative to arm 23. This is accomplished by neck 71.Neck 71 is substantially similar to that discussed in FIG. 2a but forthe fact that suction device 13 has suction paddle 22 at an angledorientation to suction arm 23. In the preferred embodiment suctionpaddle 22 of suction device 13 is perpendicular to suction arm 23,although other angular orientations may be used.

FIG. 3b is a view of the bottom of suction device 13. As seen, in thepreferred embodiment suction paddle 22 of suction device 13 issubstantially similar to that described in FIG. 2b. In the preferredembodiment suction aperture 32 has a diameter of 2 mm and suction port33 has a diameter of 6 mm.

FIG. 4 is a longitudinal cross-sectional view of suction paddle 22 usedin immobilizing device 11. As seen, paddle 22 has a series of suctionports 33 each of which is connected to suction conduit 31 through asuction aperture 32. Each suction port 33 has generally straight,cylindrical sides. Of course other configurations may be used, such ascone-shaped suction ports, dome-shaped suction ports, etc. As can beseen through this FIG. it is the bottoms or ends themselves of thesuction ports define a generally planar surface through the ends of eachport along the bottom surface of the paddle. Moreover, although shownhere as conjoined or defining a continuous surface, suction ports may befurther arranged such that they are each separate and distinct from oneanother, but which would still define a planar surface along throughtheir ends along the bottom of the paddle.

FIG. 5 is a cross-sectional view of the suction paddle 22 taken alongthe line 5—5 of FIG. 4. As seen, suction port 33 is connected to suctionconduit 31 through suction aperture 32. Suction paddle 22 has a cantedor slanted surface 36 at the top. Through this type of surface, area 37may be better accessed for performing surgical procedures.

FIG. 6 is a longitudinal cross-sectional view of suction arm 23. Distalend 71 of suction arm 23 has neck 71 (not shown in this FIG.) fixedthereto. As seen, arm 23 has a suction lumen 30 therethrough whichcommunicates with suction conduit 31 in paddle 22 through neck lumen 72of neck 71 (shown in phantom in this FIG.). As seen in FIG. 7, which isa plan view of suction arm 23, proximal end 75 has a series of knurledridges 76 to facilitate coupling a suction line coming from suctionsource (not shown in this FIG) to suction arm 23.

FIG. 8 is a detailed view of a pair of suction devices 12, 13 beingpositioned on a heart and spread apart. As seen, paddles 22, 27 of eachdevice generally are placed in the area 34 in which temporaryimmobilization of the heart tissue is desired. When used for a coronarybypass graft, area 34 typically will have a coronary artery 35 runningtherethrough. Area 34 is between paddles 22, 27. Once placed about area34, suction is then created in the suction ports (not shown in thisview.) Through the suction, the device then is fixed to or grabs hold ofthe heart tissue.

Once the suction is created and the paddles are secured to the hearttissue, each of the suction devices are then spread slightly apart asshown by the arrows 40, 41 to the positions shown as 42, 43. The effectof this spreading apart is to cause a tension to be created in the area34 of the heart tissue between the paddles. The tension causes the area34 to be further immobilized, and in particular in the Z-direction, i.e.in the direction normal to the plane defined by the surface of theheart. This is represented in FIGS. 9 and 10.

As seen in FIG. 9, the area of heart tissue between the paddles, evenwith the placement of the paddles, still has some vertical motion, shownhere as arrow 50. When paddles 22, 27 are slightly spread apart to causea tension in that area 34 of tissue between the paddles, as depicted inFIG. 10, then the amount of movement in the area 34 between the paddles22, 27 due to the tension is further decreased, especially in theZ-direction, i.e. the direction perpendicular to the surface of theheart 1. Once the paddles 22, 27 are thus positioned and secured and thearea of the tissue is temporarily immobilized, the coronary artery inthat area may be operated upon.

In the preferred embodiment, the anastomosis of the coronary artery maybe accomplished through any acceptable end-to-side or side-to-sidetechnique. Of course, other methods of performing the anastomosis may beused, such as those methods which may be performed endoscopically.

FIG. 11 is an example of the motion in the plane parallel to the surfaceof the heart of a point on heart tissue during one half respiratorycycle when the heart is unrestrained and also depicting the motion ofthe same point on heart tissue when the suction devices are used. Line60 is a tracing of the motion of a point of tissue on the cardiacsurface. As seen by line 60, a point on the cardiac surface movesapproximately 15 mm in each direction. Generally, each loop of movementdepicts the motion of the beating heart within one cardiac cycle. Thus,loop 61 occurs due to one cardiac cycle. Loop 62 occurs due to the nextcardiac cycle, but the entire heart has shifted in location somewhat dueto the inflation or deflation of the lungs associated with respiration.Line 63 shows the motion of the same point of heart tissue when thesuction device is placed near the area and the heart wall is immobilizedby the present invention. As seen, the present invention functions tominimize heart wall movement in that area to approximately 1 mm in eachdirection. This is best seen in FIG. 12 which is an enlarged portion ofFIG. 11 and in particular line 63. As seen, through the use of thepresent invention, heart wall movement has been decreased to onlyslightly more than 1 mm. Decreased to an amount in the area of thesuction devices such that the still-beating heart may be operated uponin that area using an endoscope or any other method of minimallyinvasive surgery.

FIG. 13 is an alternate embodiment of the present invention. As seen,the embodiment of FIG. 13 comprises a suction sleeve 80 which is coupledto an annular suction head 81 via a ball bearing joint 84. Ball bearingjoint 84 may be provided so as to permit remote actuation of the suctionhead 81 from a position outside the chest. The suction head 81 has aseries of suction ports 82 located along a first planar surface. In theembodiment shown the planar surface upon which the suction ports 82 arelocated is conical in shape, although other types of planar surface maybe used, such as frusto-conical for example. The suction head 81 may beconstructed such that each half of the device is coupled to a separatesuction source. Through such a configuration, if one-half of the suctionhead 81 were to lose contact with the surface, the other one-half of thesuction head 81 could maintain capture. The suction sleeve 80 is used asdescribed above. That is the suction sleeve 80 itself is coupled to asuction source (not shown but the same as suction source 114) and isfixed or immobilized to a stationary point, such as the operating tableor a retractor (also not shown.) Suction through the suction source andthe suction sleeve 80 then causes the suction ports 82 to suck upon theheart tissue. Through this configuration, then, the heart tissue in thecenter of suction sleeve is immobilized. Interruption or opening 83permits suction head 81 to be fixed to heart tissue while permitting ablood vessel to be grafted. In particular, if a mammary artery has beengrafted end-to-side to a coronary artery, then the opening 83 permitsthe suction head 81 to be removed from around the grafted artery.

FIG. 14 is a view of the device being used to temporarily immobilize alocal area of heart tissue using an alternative access procedure to thepreferred mini-thoracotomy. In particular heart 1 is exposed with anincision 2 through the patient's sternum and the chest is spread apartby a retractor 3 to provide access to the heart 1. Access to the heart 1is further effected by retraction of the pericardium 4 in the area ofthe heart 1 which is to be operated on. As shown pericardial retractionis accomplished through sutures 5.

As seen, the immobilizing device 11 comprises a pair of suction devices12, 13 and a suction source 114. Suction devices 12, 13 are secured topatient be securing each to retractor 3 through a pair of clamps 19. Ofcourse suction devices 12, 13 may also be secured to the operating table(not shown in this FIG. but using a securing device as described above.)Suction devices are coupled to suction source 114 through lines 20, 21.Suction source 114 is preferably the standard suction available in theoperating room and coupled to the devices with a two liter buffer flask(not shown) for each device. Suction is provided at a negative pressureof between 200-600 mm Hg with 400 mm Hg preferred. As seen, each suctiondevice has essentially two portions, a paddle 22 and an arm 23.

Turning now to FIG. 15 which is a side view of an alternate embodimentof suction device 12 showing its placement against the outline of aheart. As seen, the distal end of suction device comprises a paddle 22and arm 23. Paddle 22 has a generally planar surface which conformsgenerally to the curvature of a heart 1, shown here in outline. Thepaddle 22 is coupled to arm 23 through a pin 24. The pin 24 permits thepaddle 22 to be swiveled to the preferred angle relative to arm 23. Asseen, arm 23 has a suction lumen 30 therethrough which communicates witha suction conduit 31 in paddle 22. Suction conduit 31, in turn,communicates through suction aperture 32 (best seen in FIG. 4) tosuction port 33.

FIG. 16 is a view of the bottom of suction device 12 shown in FIG. 15.As seen, four suction ports 33 in a row are featured, although thespecific or exact number and position used may vary.

FIG. 17 is a further alternate embodiment of a suction device 12 showingits placement against the outline of a heart. As seen, suction device 12is substantially similar to that shown and described in FIG. 2, but forthe addition of suture coil 73. Suture coil 73 is a tightly wound springfixed to the top surface of suction paddle 22. Further temporarystabilization of the coronary anastomosis site may be achieved, ifdesired, by catching epicardial flaps with light traction sutures.Suture coil 73 permits these and any other sutures to be temporarilyfixed in place by wedging the suture between within suture coil 73, asis known in the art.

FIG. 18 is a bottom view of a further alternate embodiment of suctiondevice 12. As seen, suction device 12 is substantially similar to thatshown and described in FIG. 2, but for the addition of electrode 174along a side of suction paddle 22. Electrode 174 is coupled by lead 175to pulse generator 176. Electrode 174, lead 175 and pulse generator 176may be provided according to well know methods and materials so as topermit the heart to be paced, cardioverted or defibrillated whilesuction device 12 is fixed to the surface of the heart.

FIG. 19 is a cross-sectional view of a body showing an alternate methodof achieving access to a surface of the heart and using the presentinvention to immobilize an area of tissue. As seen suction device 12 isintroduced through a first stab wound. As discussed above, suction arm23 of device 12 is secured by securing device 14 to a stationary object,such as operating table 16. A second suction device may also beintroduced through a second stab wound to securely immobilize a localarea of tissue. Each suction device has a covering 180, made from latexrubber, over the distal end when it penetrates the chest wall in orderto avoid blood and tissue from entering the suction ports and blocksuction apertures. Two or more additional surgical trocars 78 may beintroduced to permit endoscopy and surgical access to heart 1. Inaddition the left lung 79 may also be partially collapsed so as toprovide an unencumbered area in which to manipulate the surgicalinstruments.

FIG. 20A is a cross-sectional view of a body showing an alternateembodiment of the present invention, and in particular, an alternateembodiment of the securing device. In this embodiment, securing devicecomprises a pair of anchors 201, 202 which are attached to surgicaltable 203. As seen, surgical table is attached by pedestal 204 to thefloor 205. Each anchor is attached on either side of the table using apair of fasteners 206, 207. In the preferred embodiment, fasteners are apair of screws which couple with longitudinal slots within each anchorto permit the anchors to be adjusted both in an inward and outwarddirection as well as up and down, as shown by the arrows. As seen,anchors are designed to follow the contour of patient 210 to therebyprovide a smooth surface over which a surgeon may operate. Each anchoris attached to retractor 3 by fasteners 211, 212. On the retractor 3 amounting rail 999 is attached, best seen in FIG. 20B discussed below.Attached in turn to mounting rail is a pair of slip-grip type holders12A, 13A or any other holder which permits an object to be quickly butsecurely mounted or removed, and mounted in turn to holders are a pairof suction devices 12B, 13B as has been already previously discussedabove. In the preferred embodiment, each anchor is a strip ofbiocompatible metal, such as stainless steel, approximately 5-8centimeters in width and 0.6-0.8 centimeters in thickness. As seenpositioned at the bottom of anchors is a truss. In particular eachanchor has fixed to it a descending member 216, 217, each of which arelinked together by a pair of cross-braces 218, 219. Cross-braces may ormay not be coupled together at their center points. As can beappreciated, through this truss construction the stability of anchorsand thus the suction devices mounted thereto is increased.

FIG. 20B is a top view of the embodiment shown in FIG. 20A. As seen,mounted to anchors 201, 202 is a mounting rail 999. In the preferredembodiment mounting rail is ellipsoidal in shape. As seen mounting railis used to mount slip-grip type holders 12A, 13A and their correspondingsuction devices. To be precise, mounting rail permits the suctiondevices to be securely mounted but yet be easily moved in the area ofthe surgical procedure. The ellipsoidal shape, moreover, correspondsmore suitably to the surgical area. Of course, other shapes may also beused, such as circular, or non-symmetrical, for example. Of course otherconfigurations of a mounting rail, retractor and anchor may be used,such as a retractor integral with the anchors or a mounting railintegral with the retractor or both, to mention only two of the manypossibilities.

In use, access to the heart is achieved and retraction of the chest wallis performed prior to the positioning of the anchors. Once the heartaccess is achieved, the retractor is coupled to the anchors and theanchors are then fixed to the table. At this point, the retractor isthus immobilized with respect to the table and provides a stationaryobject to which the immobilizing device featuring the a pair of suctiondevices 12B, 13B may be coupled.

FIGS. 21 and 22 depict a further alternate embodiment of the securingdevice. FIG. 21 is a perspective view of a securing device. As seen, inthis embodiment, the securing device comprises a pair of formed rails220, 221. As seen, each rail is coupled to the surgical table 203through a series of screws 222, 223.

Although not shown in the FIGS. each rail further features a truss-likestructure such as that shown in FIG. 20 A which is positioned below thetable which provides additional rigidity and stability. As seen, eachrail is further formed to slope inwardly toward the patient 210 (shownin outline in this FIG.) This provides for access above the patient bythe surgeon. Straddling between each rail is a mounting 224. Themounting is adjustable along the rail. The mountings are furtherdesigned to have a suction device mounted thereto. In such a manner, themounting 224 and rails 220, 221 provide a stationary object to which thesuction device may be mounted.

FIG. 22 depicts an overhead view of the rails 220, 221 used to positiona suction device to the heart. As seen, in this embodiment, two suctiondevices 225, 226 are fastened to the mounting using a pair of slip-griptype holders 12A, 13A as already discussed above.

Turing now to FIG. 23 which is a side view of an alternate embodiment ofsuction device 12. As seen this alternate embodiment of suction device12 features a suction port 33 as already described above. Each suctionport is connected to a suction conduit 31 through a suction aperture 32as also already described above. In this embodiment, however, thesuction device further provides for the distribution of irrigation fluidonto the area of the heart where an anastomosis will be performed. Asseen, the irrigation fluid source 133 is coupled by an irrigation line134 to the irrigation fluid conduit 135. The irrigation fluid conduit,in turn, is coupled to an irrigation hose 136. As shown, irrigation hoseis designed to have some flexibility to permit it to be rotated andmoved along several angles and is preferably a braided stainless steelhose. Irrigation hose dispenses irrigation fluid at its end. Irrigationfluid preferably is a warm saline mist which prevents the exposedtissues from drying out. Moreover, the fluid is dispensed under pressuresuch that the mist has a force to it which permits the mist to be usedto blow with sufficient force to assist in holding open a coronaryartery such that the anastomosis may be performed more easily. Suctiondevice further features a return irrigation fluid circuit. As seen,return irrigation fluid circuit comprises a return irrigation port 140which is coupled to a return irrigation conduit 141. Return irrigationconduit is coupled to a suction source to provide suction to returnirrigation pipe 142 such that the irrigation fluid which is dispensedmay be readily removed from the surgical area. Although shown as anintegral part of the suction device, both the irrigation system as wellas the suction system may or may not be a part of the suction device.

FIG. 24 is a further alternate embodiment of a suction device. As seen,suction device features the suction port, suction conduit and suctionaperture as already described above. In this embodiment, however, thesuction device further features an optical fiber 150 which is coupled atone end to the area of the suction device where the anastomosis will beperformed and is further coupled to a light source 151. In this manner,the suction device may be used to provide additional light 152 to thearea where the anastomosis will be performed.

FIG. 25 is a perspective view of an alternate embodiment of animmobilizing device 11. As seen, in this embodiment, each suction deviceis coupled to a mounting beam 998 through a pair of holders 12A, 13A asalready described above with reference to FIG. 20A. Mounting beam 998features two sections, each of which may be individually rotated aboutor spread apart or both. In particular mounting beam has a central screwmembers 997, 996. Each central screw member has an actuating knob 994,995 at an end thereof. Rotation of each knob thereby causes the suctiondevice mounted to that portion of the mounting beam to move either awayor towards the center of the mounting beam, as indicated by line 993.Mounting beam 998 is mounted to a stationary object, such as aretractor, mounting rail or fixation arm, through a central arm 992.Each suction device may further be rotated relative to the mounting beamthrough simply moving each of the relevant devices, as indicated by thelines 991, 990. The use of mounting beam to retain suction devices is ofuse when only one fixation arm is to be used. In such a manner mountingbeam permits both device to be fixed to a stationary object as well aspermitting suction devices to be moved apart to thereby provideadditional immobilization to a local area of tissue, as discussed abovewith regards to FIGS. 8-10.

FIG. 26A is a view of the bottom of an alternate embodiment of suctionpaddle 22 used in the immobilizing device. As seen, paddle has a seriesof suction ports, each of which is connected to suction conduit througha suction aperture. In this embodiment, the paddle features five suctionports. The additional side suction port is presented on the side of thesuction paddle which will not be near the coronary artery or, ingeneral, the surgical target. The additional port increases the suctionsurface area. Each suction port 33 has a 6 mm diameter while eachsuction aperture 32 has a 2 mm diameter.

FIG. 26B is a perspective view of the bottom of an alternate embodimentof suction paddle 22 used in the immobilizing device. As seen in thisembodiment the paddle 22 is oriented at a ninety degree angle relativeto the neck portion 71 and arm 23. Of course paddle may also be orientedat another suitable angle other than ninety degrees relative to neckportion. In this embodiment, the paddle features four suction ports,although more or less ports may also be provided. Each suction port 33has a 6 mm diameter while each suction aperture 32 has a 2 mm diameter.

FIG. 27 is a perspective view of a turning handle 161 used to bend ororient the suction paddle 22 portion of the immobilizing device. Asdiscussed above neck 71 is fashioned to be relatively bendable, asopposed to paddle 22 and arm 23. As seen, handle 161 features opening980 having the same shape and dimension of paddle such that paddle maythus be inserted therein. Handle also features neck portion 982 and gripportion 981, Neck and grip portion are dimensioned to provide leverageagainst opening 980 and thus paddle, neck and arm. To use, paddle isinserted into opening. Once inserted manipulation of grip portionrelative to arm causes bending in the area of neck. Such a handle may beadvantageous as compared to bending of the device by hand in that itavoids the surgeon from straining hand muscles which will be needed toperform delicate manipulations.

FIG. 28 is a bottom view of an alternate embodiment of immobilizingdevice 11. As seen, immobilizing device features a pair of suctionpaddles 171, 172, each of which is coupled to an arm by a continuoushinge or neck as discussed above. The arm in turn, is coupled to astationary object, also discussed above. In this embodiment, the armsare further fastened together using a spreader 180. As seen, spreader180 permits the arms to be moved relatively apart or together. Asalready discussed above, the movement of the arms apart is performedonce the paddles are engaging by suction the surface of the heart tothereby increase epicardial tension locally and thus dampen or decreasethe motion of the surface of the heart due to the intrinsic beating ofthe heart. Spreader also functions to provide additional stability topaddles due to its function as a truss-like member.

Turning to FIG. 29, spreader 180 comprises a pair of bars 181, 182 whichare coupled together using a wing nut 183. One bar features anengagement pin 184 while the other bar features an engagement slot 185.Each bar is further coupled to each of the respective arms of theimmobilizing device by a respective lumen 186, 187. In such a manner,each bar is securely coupled to each arm. By longitudinally manipulatingeach of the bars apart as shown by arrow 188, each arm and thus eachpaddle may be securely positioned relatively closer or further apart.

FIG. 30 depicts an alternate embodiment of spreader 180. As seen,spreader features a pair of bars which couple to each of the arms of arespective suction device, as described above. Bars are further coupledtogether using gearing 190. Gearing, in turn, is coupled to a motor 191.As seen, motor is further coupled to a power source 192. Coupling bothmotor and power source together is a control 193. Control automaticallydetects the amount of spread within the suction devices caused byspreader. In the preferred embodiment, control senses the amount ofpower or energy required by motor to further spread spreader and thussuction paddles apart. When a threshold amount is reached, control shutsdown the source of power for motor, thereby locking the spreader in thepresent position. The feature thus permits a spreader to automaticallyspread the suction paddles apart to a degree sufficient to dampen wallmotion without permitting the spreader to spread paddles apart too muchsuch that capture of the heart wall due to suction is lost. Of course,further designs to control the spreading of suction paddles may also beused, such as other mechanical or hydraulic actuated or controlledsystems.

FIG. 31 depicts an alternate embodiment of immobilizing device and, inparticular, an alternate embodiment of the securing device used tosecure each suction paddle. As seen this system features a pair of arms351, 351 having a ball and socket construction. As seen each armfeatures at its free end a slip and grip-type holder 12A and 13A asdiscussed above. The opposite end of each arm fits into a footing 970,971. Each footing is lockable to a rail clamp unit 968, 969 which locksonto the rail 901, 902 at the side edges of table 203. Positioned at thebottom of rail clamp unit is locking actuator 967, 968. Each lockingactuator cooperates within the arm to thereby cause the arm to be lockedinto position when the respective handle is turned in one of thedirections indicated by arrows 965. In particular locking actuatorcauses a cable located with the respective arm to tighten, which, due tothe ball and socket construction thereby causes the arm to be lockedinto position. Positioned at the bottom of each locking actuator is atruss. In particular each locking actuator has fixed to it a descendingmember 216, 217, each of which are linked together by a pair ofcross-braces 218, 219. Cross-braces may or may not be coupled togetherat their center points. As can be appreciated, through this trussconstruction the stability of anchors and thus the suction devicesmounted thereto is increased, as described earlier in FIG. 20A.

FIG. 32 is a cross sectional view of an arm shown in FIG. 31, and inparticular showing a detail of the ball and socket construction. As seenonly one portion is shown to illustrate the ball and socketconstruction. Each tube 800 (several of which are used to create arm)has its end fashioned to correspond to the shape of the ball 801, thatis each relevant end of tube features a hemispherical hollow having aradius which corresponds to the outer surface of the ball such that alarger portion of the tube contacts the ball as compared to if the endof the tube were only cut straight across. This geometry increases thesurface area between the tube and each ball which thereby increases thestability of the arm when fixed into position. Each ball 801 furtherfeatures an internal bushing 802. As seen each internal bushing isshaped to have a tapered opening 803 at each end. Positioned through thelength of arm, and in particular within each tube element and ball iscable 804. Cable is preferably constructed from kevlar and features apolyurethane covering and is fastened to either end of the arm such thatby tensioning the cable the ball and tube portions are brought togetherand fixed in relation due to friction. The operation of arm is asfollows. When no tension is placed on the cable, each tube element mayslip relatively easily relative to each ball. Tension on the cable,however, increases the friction between tube and ball. Sufficienttension thereby results in the ball and tube becoming immovable relativeto each other. The taper 803 within each bushing 802 permits the cableto remain at the same length regardless of the orientation of each tubeelement and each ball. That is, if the arm is bent and has a radius ofcurvature, the taper permits the cable to remain at the same lengthregardless. This thus permits the arm to be more easily moved andthereafter locked into place.

FIG. 33 depicts a further alternate embodiment of the present invention,and in particular of a suction device substantially similar to thatshown in FIG. 13 but for that two separate sets of suction ports arelocated at the top of the suction paddle. As seen each suction line hasa stopcock 861, 862 to permit either or both sets of related suctionports to be independently disconnected from their respective suctionsource. Arm 823 contains lumens for each suction line and ends wherenecks 871, 872 begin, As discussed above, each neck is designed to bend.Suction paddle is mounted to necks and as seen features an encirclingarray of suction ports, located at the upper surface of the paddlerelative to the arm. Suction paddle features sixteen suction ports,arranged as a set of eight along one side 81 coupled to one suction lineand a second set of eight along another side 82 coupled to anothersuction line. Through this arrangement even if one side loses capturewith the tissue, because the other side is coupled to another suctionsource, pressure is not lost on that side and capture in that area ismaintained. In the embodiment shown the suction ports are located alonga generally conical planar surface at the top of the paddle, althoughother types of planar surfaces may be used, such as frusto-conical forexample. The orientation of the suction ports along the top of theencircling paddle is most useful to access the posterior or backside ofthe heart so as to move or reposition the heart to achieve better accessto areas which would otherwise be difficult to access.

To further assist in the exposure of the surgical site, accessretractors may also be used in conjunction with the immobilizing device,such as spoon shaped probes to move other tissue from the area ofsurgical interest.

As disclosed, the present invention relates to a method and apparatusfor immobilizing tissue. In the preferred embodiment, the invention isused to immobilize heart tissue for a coronary artery bypass graftprocedure using either an open or closed chest approach, without theneed for a cardiopulmonary bypass. Other surgical techniques, however,which require immobilizing body tissue may also be performed using thepresent invention, such as surgery on other organs such as the stomach,gall bladder, etc., as well as on other body tissues, such as the eye orthe skin, for example. In addition, while the present invention has beendescribed in detail with particular reference to a preferred embodimentand alternate embodiments, it should be understood variations andmodifications can be effected within the scope of the following claims.Such modifications may include substituting elements or components whichperform substantially the same function in substantially the same way toachieve substantially the same result for those described herein.

What is claimed is:
 1. A device for immobilizing an area of tissuecomprising: a retractor; a first member having a suction port along afirst plane; a second member having a suction port along the firstplane, the second member positioned apart from the first member suchthat an immobilized area is defined between; a securing device to fixthe first member and the second member to the retractor, the securingdevice coupled to the first member and the second member.
 2. The deviceof claim 1 wherein the securing device comprises a first variablefriction arm having at a first lockable elbow joint and a secondvariable friction arm having at a second lockable elbow joint.
 3. Thedevice of claim 1 further comprising a first suction source coupled tothe first member and communicating with the suction port of the firstmember and a second suction source coupled to the second member andcommunicating with the suction port of the second member.
 4. Surgicalapparatus for use in a surgical procedure performed on a beating heart,the apparatus comprising: a retractor adapted to be mounted to a portionof the patient's skeletal system; a first device including a first armmounted on the retractor and a first member coupled to the first arm,the first member having a first contact surface for contacting thesurface of the heart and a suction conduit open to the atmospherethrough the first contact surface; and, a second device including asecond arm mounted on the retractor and a second member coupled to thesecond arm, the second member having a second contact surface forcontacting the surface of the heart.
 5. The apparatus of claim 4 furthercomprising a suction source coupled to the first member andcommunicating with the suction conduit.
 6. The apparatus of claim 4further comprising a first clamp for mounting the first device on theretractor, and a second clamp for mounting the second device on theretractor.
 7. The apparatus of claim 4 wherein the first membercomprises a suction port in fluid communication with the suction conduitand positioned along the first contact surface.
 8. The apparatus ofclaim 7 wherein the suction port is generally cone-shaped.
 9. Theapparatus of claim 7 wherein the suction port is generally dome-shaped.10. The apparatus of claim 7 wherein the suction port is generallycylindrical-shaped.
 11. The apparatus of claim 4 wherein the secondmember includes a suction lumen open to the atmosphere through thesecond contact surface.
 12. The apparatus of claim 11 further comprisingone or more suction source(s) in fluid communication with the suctionlumen of the first member and the suction member of the second member.13. The apparatus of claim 12 wherein the second member comprises asuction port in fluid communication with the suction lumen andpositioned along the second contact surface.
 14. The apparatus of claim13 wherein the suction port is generally cone-shaped.
 15. The apparatusof claim 13 wherein the suction port is generally dome-shaped.
 16. Theapparatus of claim 13 wherein the suction port is generallycylindrical-shaped.
 17. The apparatus of claim 4 further comprising asuture fixation member.
 18. The apparatus of claim 4 wherein the firstor second contact surface include one or more electrodes.
 19. Theapparatus of claim 18 further comprising a pulse generator and lead, theelectrodes being coupled by the lead to the pulse generator.
 20. Theapparatus of claim 4 wherein at least one of the first and seconddevices further comprises a means for dispensing or removing a fluidalong the surface of the heart.
 21. The apparatus of claim 4 wherein atleast one of the first and second devices further comprises a means fordelivering light to the surface of the heart.
 22. The apparatus of claim4 wherein the first member is coupled to the first arm by hinge or jointpermitting the first member to move relative to the first arm.
 23. Theapparatus of claim 22 wherein the hinge or joint is a ball bearing jointthereby permitting the first member to rotate relative to the first arm.24. The apparatus of claim 22 wherein the hinge or joint comprises a pinthereby permitting the first member to swivel relative to the first arm.25. The apparatus of claim 4 wherein the second member is coupled to thesecond arm by hinge or joint that may be moved or locked into positionthereby permitting the second member to move relative to the second arm.26. The apparatus of claim 25 wherein the hinge or joint is a ballbearing joint thereby permitting the second member to rotate relative tothe second arm.
 27. The apparatus of claim 25 wherein the hinge or jointcomprises a pin thereby permitting the second member to swivel relativeto the second arm.
 28. The apparatus of claim 4 wherein at least one ofthe first and second arms is bendable.
 29. The apparatus of claim 4wherein at least one of the first and second arms includes at least onejoint or hinge that may be moved or locked into position.
 30. Theapparatus of claim 4 wherein the first or second arm is a variablefriction arm.
 31. The apparatus of claim 4 wherein the first or secondarm has a ball and socket construction that may be moved or locked intoposition.
 32. The apparatus of claim 31 wherein the ball and socket armcomprises a plurality of tube elements jointed together by a pluralityof ball elements, the tube elements having socket ends shaped to matewith the ball elements, a cable disposed throughout the series of ballelements and tube elements and a locking actuator coupled to the cable,the locking actuator being capable of tightening the cable to lock theball and socket arm into a rigid position.
 33. The apparatus of claim 32further comprising a means for maintaining the same length of the cablewithin the ball and socket arm regardless of the orientation of any tubeelement to an adjacent ball element.
 34. The apparatus of claim 33wherein the means for maintaining the same length of the cable withinthe ball and socket arm comprises tapered bushings positioned within thelumen of the ball elements, the tapered bushings having a passage waythereout which has a first diameter at a first end, a second diameter inthe middle and a first diameter at an end opposite the first end, thefirst diameter being larger than the second diameter.
 35. The apparatusof claim 4 wherein the first or second arm has a proximal end and adistal end, the first or second arm comprising: a plurality of links,the links being free to move relative to one another so that the armarticulates; a cable extending through the links, the cable having adistal end and a proximal end; a locking actuator coupled to theproximal end of the cable and the proximal end of the arm to tension thecable thereby locking the links relative to one another so that the armchanges from an articulating condition to a locked rigid condition. 36.The apparatus of claim 35 wherein the locking actuator comprises arotatable handle coupled to the proximal end of the arm wherein rotatingthe handle changes the arm from the articulating condition to the lockedrigid condition.
 37. A medical device to facilitate a surgical procedureto be performed on a beating heart comprising: a first suction devicefor temporarily engaging a first area of tissue of the beating heart,the first suction member having a first contact surface adapted to beplaced against the heart, the first suction member having a suctionconduit open to the atmosphere through the first contact surface, thefirst suction member coupled to a first arm; a first suction linecoupled to the suction conduit wherein suction to the first suction lineis communicated to the suction conduit; a first securing device coupledto the first arm; a second suction device for temporarily engaging asecond area of tissue of the beating heart, the second suction devicehaving a second suction member, the second suction member having asecond contact surface adapted to be placed against the heart, thesecond suction member having a suction lumen open to the atmospherethrough the second contact surface, the second suction member coupled toa second arm; a second suction line coupled to the suction lumen whereinsuction to the second suction line is communicated to the suction lumen;a second securing device coupled to the second arm; and, a retractorcoupled to the first and second securing devices for fixing the firstand second suction devices to a portion of a patient's skeletal system.38. The medical device of claim 37 wherein the first or second arm isbendable.
 39. The medical device of claim 37 wherein the first or secondarm includes at least one joint or hinge that may be moved or lockedinto position.
 40. The medical device of claim 37 wherein the first orsecond arm is a variable friction arm.
 41. The medical device of claim37 wherein the first or second arm has a ball and socket constructionthat may be moved or locked into position.
 42. The medical device ofclaim 41 wherein the ball and socket arm comprises a plurality of tubeelements jointed together by a plurality of ball elements, the tubeelements having socket ends shaped to mate with the ball elements, acable disposed throughout the series of ball elements and tube elementsand a locking actuator coupled to the cable, the locking actuator beingcapable of tightening the cable to lock the ball and socket arm into arigid position.
 43. The medical device of claim 42 further comprising ameans for maintaining the same length of the cable within the ball andsocket arm regardless of the orientation of any tube element to anadjacent ball element.
 44. The medical device of claim 43 wherein themeans for maintaining the same length of the cable within the ball andsocket arm comprises tapered bushings positioned within the lumen of theball elements, the tapered bushings having a passage way thereout whichhas a first diameter at a first end, a second diameter in the middle anda first diameter at an end opposite the first end, the first diameterbeing larger than the second diameter.
 45. The medical device of claim37 wherein the first or second arm has a proximal end and a distal end,the arm comprising: a plurality of links, the links being free to moverelative to one another so that the arm articulates; a cable extendingthrough the links, the cable having a distal end and a proximal end; alocking actuator coupled to the proximal end of the cable and theproximal end of the arm to tension the cable thereby locking the linksrelative to one another so that the arm changes from an articulatingcondition to a locked rigid condition.
 46. The medical device of claim45 wherein the locking actuator comprises a rotatable handle coupled tothe proximal end of the arm wherein rotating the handle changes the armfrom the articulating condition to the locked rigid condition.
 47. Themedical device of claim 37 wherein the first securing device or secondsecuring device comprises a clamp adapted to be coupled to theretractor.
 48. The medical device of claim 37 wherein at least one ofthe first and second suction devices further comprises a means fordispensing or removing a fluid along the surface of the heart.
 49. Themedical device of claim 37 wherein at least one of the first and secondsuction devices further comprises a means for delivering light to thesurface of the heart.
 50. The medical device of claim 37 furthercomprising a suture fixation member.
 51. The medical device of claim 37wherein the first or second contact surface comprises one or moreelectrodes.
 52. The medical device of claim 51 wherein the electrodesare coupled by a lead to a pulse generator.
 53. The medical device ofclaim 37 wherein the first member is coupled to the first arm by hingeor joint that may be moved or locked into position thereby permittingthe first member to move relative to the first arm.
 54. The medicaldevice of claim 53 wherein the hinge or joint is a ball bearing jointthereby permitting the first member to rotate relative to the first arm.55. The medical device of claim 53 wherein the hinge or joint includes apin permitting the first member to swivel relative to the first arm. 56.The medical device of claim 37 wherein the second member is coupled tothe second arm by hinge or joint that may be moved or locked intoposition thereby permitting the second member to move relative to thesecond arm.
 57. The medical device of claim 56 wherein the hinge orjoint is a ball bearing joint thereby permitting the second member torotate relative to the second arm.
 58. The medical device of claim 56wherein the hinge or joint comprises a pin permitting the second memberto swivel relative to the second arm.
 59. The medical device of claim 58wherein the second suction member comprises a neck which is used tocouple the second suction member to the second arm.
 60. The medicaldevice of claim 59 wherein the neck of the second suction member iscoupled to the second arm by a hinge or joint permitting the secondmember to move relative to the second arm.
 61. The medical device ofclaim 60 wherein the suction lumen of the second suction member extendsthrough the neck of the second suction member.
 62. The medical device ofclaim 61 wherein the neck of the second suction member is bendable. 63.The medical device of claim 61 wherein the neck of the second suctionmember is rigid.
 64. The medical device of claim 37 wherein the firstsecuring device includes a first clamp for clamping on the retractor,and the second securing device includes a second clamp for clamping onthe retractor.
 65. The medical device of claim 37 wherein the firstsuction member is coupled relatively perpendicular to the first arm, andthe second suction member is coupled relatively perpendicular to thesecond arm.
 66. The medical device of claim 37 wherein the first andsecond suction lines are coupled to a suction source.
 67. A systemcomprising a patient having a beating heart, and a medical device tofacilitate a surgical procedure to be performed on the beating heart,the medical device comprising: a suction source; a first suction devicefor temporarily engaging a first area of tissue of the beating heart,the first suction device having a first arm and a first suction member,the first suction member coupled to the first arm, the first suctionmember having a suction conduit open to the atmosphere through a firstcontact surface in engagement with the first area of tissue, the suctionconduit coupled to the suction source; a first securing device coupledto the first arm; a second suction device for temporarily engaging asecond area of tissue of the beating heart, the second suction devicehaving a second arm and a second suction member, the second suctionmember movably coupled to the second arm such that the second suctionmember is free to move relative to the second arm, the second suctionmember having a lumen open to the atmosphere through a second contactsurface in engagement with the second area of tissue, the lumen coupledto the suction source; a second securing device coupled to the secondarm; and, a retractor coupled to the first and second securing devicesand a portion of the patient's skeletal system for fixing the first andsecond suction devices relative to a portion of the patient's skeletalsystem.
 68. A surgical apparatus for use in a surgical procedureperformed on a beating heart, of a patient, the apparatus comprising: aretractor adapted to be mounted on a portion of the patient's skeletalsystem; a first device including a first arm mounted on the retractorand a first member coupled to the first arm, the first member having afirst contact surface contacting the surface of the heart and a suctionconduit open through the first contact surface to apply suction to thesurface of the beating heart; and, a second device including a secondarm mounted on the retractor and a second member coupled to the secondarm, the second member having a second contact surface contacting thesurface of the heart.
 69. The system of claim 68 further comprising asuction source coupled to the first member and communicating with thesuction conduit.
 70. The system of claim 68 further comprising a firstclamp for mounting the first device on the retractor, and a second clampfor mounting the second device on the retractor.
 71. The system of claim68 wherein the first member comprises a suction port in fluidcommunication with the suction conduit and positioned along the firstcontact surface.
 72. The system of claim 71 wherein the suction port isgenerally cone-shaped.
 73. The system of claim 71 wherein the suctionport is generally dome-shaped.
 74. The system of claim 71 wherein thesuction port is generally cylindrical-shaped.
 75. The system of claim 68wherein the second member includes a suction lumen open to theatmosphere through the second contact surface.
 76. The system of claim75 further comprising one or more suction source(s) in fluidcommunication with the suction conduit of the first member and thesuction lumen of the second member.
 77. The system of claim 76 whereinthe second member comprises a suction port in fluid communication withthe suction lumen and positioned along the second contact surface. 78.The system of claim 68 further comprising a suture fixation member. 79.The system of claim 68 wherein the first or second contact surfaceinclude one or more electrodes.
 80. The system of claim 79 furthercomprising a pulse generator and lead, the electrodes being coupled bythe lead to the pulse generator.
 81. The system of claim 68 wherein atleast one of the first and second members further comprise a means fordispensing or removing fluid along the surface of the heart.
 82. Thesystem of claim 68 wherein at least one of the first and second devicesfurther comprises a means for delivering light to the surface of theheart.
 83. The system of claim 68 wherein the first member is coupled tothe first arm by hinge or joint permitting the first member to moverelative to the first arm.
 84. The system of claim 83 wherein the hingeor joint is a ball bearing joint thereby permitting the first member torotate relative to the first arm.
 85. The system of claim 68 wherein thesecond member is coupled to the second arm by hinge or joint permittingthe second member to move relative to the second arm.
 86. The system ofclaim 85 wherein the hinge or joint is a ball bearing joint therebypermitting the second member to rotate relative to the second arm. 87.The system of claim 68 wherein the first or second arm is bendable. 88.The system of claim 68 wherein the first or second arm includes at leastone joint or hinge that may be moved or locked into position.
 89. Thesystem of claim 68 wherein the first or second arm is a variablefriction arm.
 90. The system of claim 68 wherein the first or second armhas a ball and socket construction that may be moved or locked intoposition.
 91. The system of claim 68 wherein the first or second arm hasa proximal end and a distal end, the first or second arm comprising: aplurality of links, the links being free to move relative to one anotherso that the arm articulates; a cable extending through the links, thecable having a distal end and a proximal end; a locking actuator coupledto the proximal end of the cable and the proximal end of the arm totension the cable thereby locking the links relative to one another sothat the arm changes from an articulating condition to a locked rigidcondition.
 92. The system of claim 91 wherein the locking actuatorcomprises a rotatable handle coupled to the proximal end of the armwherein rotating the handle changes the arm from the articulatingcondition to the locked rigid condition.
 93. A device for immobilizingan area of tissue on a beating heart, the device comprising: aretractor; a first member having a first suction port; a second memberhaving a second suction port, the second member positioned apart fromthe first member such that an immobilized area is defined between; asecuring device to secure the first member and the second member to theretractor, the securing device coupled to the first member and thesecond member; and a means for spreading the first member apart from thesecond number.
 94. The device of claim 93 further comprising a means forspreading the first member apart from the second member.
 95. The deviceof claim 94 wherein the means for spreading the first member apart fromthe second member comprise a first bar fixed to the first member and asecond bar coupled to the second member, the first having a linear slotand the second bar having means for engaging the linear slot and fixingthe second bar to the first bar.
 96. The device of claim 95 wherein themeans for spreading the first member apart from the second membercomprise motor means coupled to the first member and the second memberto cause the first member to move apart from the second member, powermeans coupled to the motor means to power the motor means, and controlmeans couple to the motor means and the power means to control theoperation of the motor means.